The Heart and Science of Parenting

Why Consider Delayed Cord Clamping?

by Alice Callahan on October 11, 2012

I first heard about delayed cord clamping as a doctoral student in Nutrition at UC Davis. One of my professors, along with her graduate students, was conducting research on delayed cord clamping in Mexico. Their findings were exciting, and their research was eventually published in the Lancet [1]. I remember being impressed that a simple change in protocol at the birth of a baby – effectively, a non-intervention – could have a profound effect on that baby’s health.

Fast-forward five years, when I was pregnant with Cee in 2010. My OB was an attending physician at an academic hospital and very knowledgeable. However, even she was skeptical when I told her that I was interested in delayed cord clamping. I emailed her a stack of journal articles showing that, at least in an uncomplicated delivery, the benefits outweigh the risks. She was convinced, and we agreed to delay clamping, providing everything went smoothly at the delivery. In the couple of years since Cee’s birth, I think delayed cord clamping has become more mainstream and in some cases, it has become standard protocol. Still, in many hospitals, you may need to advocate for delayed clamping or at least be prepared to discuss the risks and benefits with your OB or midwife.

What exactly do we mean by delayed cord clamping?

Wikimedia Commons

Delayed cord clamping means waiting 2 to 3 minutes after the delivery of an infant before clamping and cutting the umbilical cord. During this time, blood continues to pulse from the placenta to the baby until the pulses naturally stop around 3 minutes. The transfer of blood from the placenta to the baby is most effective if the baby is placed on the mother’s abdomen or lower.

What are the benefits of delayed cord clamping?

Research has found that delayed cord clamping allows 20 to 40 mL more blood to pulse from the placenta to the newborn, carrying with it an additional 30 to 35 mg of iron [2]. As a result, babies have higher newborn hemoglobin, lower risk of anemia at birth and through 2-3 months, and higher iron status and storage through 6 months of age [2, 3].

Delayed cord clamping gives your baby more iron. Why is this important? The extra iron is stored and becomes your baby’s main source of iron until she starts eating solid foods, particularly if you breastfeed. Your baby will use that iron to form red blood cells and transport oxygen, to build muscle, and to develop her brain cells. Severe iron deficiency can cause anemia, but iron deficiency during infancy (even without anemia) also increases the risk of cognitive, motor, and behavioral deficits that can last into adolescence [4-6].

How much stored iron do babies have at birth? That depends. Because the final 8 weeks of pregnancy are most important for iron storage, babies born prematurely can really come up short in iron. Size also matters; big babies are born with more iron stores than their smaller peers. Finally, maternal iron deficiency seems to increase the risk that baby will become iron deficient later in infancy. Depending on these factors, most babies will use up their stored iron between 4 and 8 months of age, after which they’ll need to get iron from fortified formula, iron supplements, or solid foods [8].

This can pose a real problem for exclusively breastfed babies, especially since both the AAP and WHO recommend waiting until babies are 6 months old to begin introducing solid foods. Breastfed babies are at higher risk for iron deficiency than those fed formula, because formula is fortified with iron. Breast milk, on the other hand, is very low in iron. (Why is breast milk so low in iron? I ruminate about that in this post.) Although breastfed babies are very efficient at absorbing that little bit of iron, the quantity is still too small to meet their needs once their iron stores have been depleted. The AAP estimates that U.S. infants that are exclusively breastfed have a 20% risk of iron deficiency by 9-12 months of age [7].

Delayed cord clamping can give babies an extra 1-3 months of iron stores to help bridge their transition from exclusive breastfeeding to solid foods [8]. This can be especially helpful for breastfed babies that are a little slow to start solid foods. Other mammals do not rush to clamp the cord immediately after birth and therefore also get that extra dose of iron to baby before cutting her off from mom’s supply. However, immediate cord clamping does not mean your baby is destined to be iron deficient – it just increases the likelihood that she will need a boost from iron supplements and/or iron-fortified foods.

An added benefit of delayed cord clamping is that it may protect your baby from lead poisoning. One study found that in breastfed infants at risk for lead exposure in Mexico, delayed cord clamping was associated with lower blood lead levels than immediate clamping [9]. This effect is probably related to the improvement in baby’s iron stores, since iron deficiency increases lead absorption. The CDC estimates that 4 million U.S. households have children exposed to lead, so this benefit has the potential to be very relevant to these kids.

Delayed cord clamping is likely even more important for preterm infants, and in fact, is beginning to be adopted by hospitals as general protocol. Preemies are at higher risk for iron deficiency. Delayed cord clamping improves hematocrit and reduces anemia and the need for blood transfusions in these babies [10]. In one trial, it also improved motor development in 7-month-old baby boys who were born prematurely [12]. In another, it increased oxygenation of brain tissue in newborn preemies [13]. Delayed cord clamping has also been shown to decrease the incidence of intraventricular hemorrhage and late-onset sepsis in preemies [10, 11]. Many of these studies used only a 30-45 second delay in cord clamping, but these benefits were observed even with this short delay.

Are there risks to delayed cord clamping?

To date, there is no evidence for significant risks to the mother or the baby associated with delaying cord clamping by 2-3 minutes. Until 2007, early cord clamping was part of the WHO protocol for preventing maternal postpartum hemorrhage, leading many practitioners to believe that late clamping might increase maternal bleeding. However, studies have found that this is not the case [14], and the WHO modified their protocol to reflect this evidence.

Delayed cord clamping does not increase an infant’s risk of jaundice, elevated bilirubin, or the need for light therapy [2, 3]. Some studies have found that delayed cord clamping increases the risk of polycythemia in newborns. Polycythemia occurs when infants have too many red blood cells in circulation – it is the opposite of anemia. However, infants with delayed cord clamping that were diagnosed with polycythemia had no symptoms and did not require treatment. Polycythemia may be a normal outcome of delayed cord clamping in some babies, and as far as we know, it does not appear to pose a health risk in these babies [2].

One other common objection to delayed cord clamping is that it is unnecessary in a developed country, because iron deficiency and anemia are only problems in developing countries. Quite simply, this is not the case. Approximately 10% of toddlers in the U.S. are thought to be iron-deficient [15]. A study in Sweden, a country with a very low prevalence of anemia, still found benefits of delayed cord clamping in this advantaged population [3].

When is delayed cord clamping not appropriate?

If a baby is born in distress and in need of resuscitation to help her breath, delaying cord clamping takes a back seat. Babies in distress need immediate attention, and it may not be practical to care for them while the cord is still attached. To get an idea of how quickly pediatricians need to assess newborn health and take appropriate action, check out their guidelines for newborn resuscitation. As more is learned about the benefits of delayed cord clamping, pediatricians may adjust their protocols to do some procedures at the bedside, allowing the cord to remain attached. In the meantime, it is my opinion that we should let them do their jobs and not ask them to practice outside of their comfort zone when it comes to caring for newborn babies. If the cord is clamped immediately, you can make up for the lost iron by giving your baby an iron supplement or feeding her iron-rich foods when she is ready for solids.

Other resources:

The Academic OB/GYN blog, written by Dr. Nicholas Fogelson, has several articles on delayed cord clamping, as well as links to a 50-minute Grand Rounds video, which is very informative. Squintmom also has a nice, well-cited article on the topic. Links to cited studies are included in the reference list below.

15. Baker, R.D. and F.R. Greer. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 126(5): p. 1040-50. 2010. Link (full text available)

(An earlier version of this post was published here, where it was hardly noticed. Maybe I’m too conservative for that crowd. Regardless, I’m having a hard time keeping my head above the water with teaching this term, much less find time to research and write sciency posts. I miss it. A lot. Teaching is good, but not as much fun. I’ll be back soon, promise.)

I had also planned to delay cord clamping at my son’s birth, however we had decided to do cord blood banking and were informed by my OB that we would not be able to do both. Based on our family’s medical history, we choose cord blood banking. Did you see any research that indicates that these two procedures are mutually exclusive?

At OHSU in Portland OR, I was able to do both. They send the stem cells to the Seattle Cord blood bank, so maybe their requirements were different, but it wasn’t a problem. I’m not sure where they got their research..

I have heard that too, my husband and I are opting of cord blood banking for our first little one, who is currently being incubated, so that we can delay cord cutting. I guess each parent has to weigh the risks and benefits for themselves, there really is no right answer here.

I love the research you laid out in this article. We had planned to delay cord clamping for our daughter, but the pediatrician found muconeum in the amniotic fluid; he explained her stomach needed to be pumped immediately at birth. Not too surprisingly, our daughter came out crying and perfectly healthy, but did show elevated bilirubin levels. With our current pregnancy, we hope to actually delay clamping to avoid the extra three days in the hospital and “baby tanning bed” treatments.

You know, I didn’t see any references to cord blood banking when reading up on delayed cord clamping. Many of the DCC studies have been conducted in developing countries, where banking is probably not available and iron deficiency is truly such a population-wide concern that DCC seems like it really should be a priority when possible. Here in the U.S., I think it is great to consider donating cord blood, but I don’t know if it is possible to collect enough cord blood for donation with DCC. You would think that a middle-of-the-road approach (wait 45 seconds – 1 min) would still give baby a significant boost in cord blood while also allowing for collection, but that’s just speculation.

That’s what I figured. I did find some anecdotal info from midwife blogs and such that said you could do DCC and still get enough for banking/donating- but nothing thoroughly researched.

Do you know what ACOG and AAP guidelines are for standard clamping procedure? I had found in the ACOG guidelines (I think) that they said donating/banking should not change standard clamping/cutting procedure, but couldn’t find anyplace that said what that standard procedure was.

Yeah, I don’t think ACOG has a standard recommendation. It may have been early clamping in the past, but I don’t think that is the case now. After the 2008 Cochrane review came out, ACOG said, “the evidence doesn’t seem sufficiently strong for a change in policy, but it does encourage a relaxed approach to the timing of cord clamping.”

I found the SOGC (Canadian organization) had an informative policy about cord blood banking that includes some discussion of timing, though they also don’t make a specific recommendation:

http://midwiferyservices.org
/umbilical_cord_clamping.htm
“In 1995 the American Academy of Obstetricians and Gynecologists (ACOG) released an Educational Bulletin (#216) recommending immediate cord clamping in order to obtain cord blood for blood gas studies in case of a future law suit. Why? Deviations in blood gas values at birth can reflect asphyxia, or lack of. Lack of asphyxia at birth is viewed as proof in a court of law that a baby was healthy at birth. Following an unpublished letter sent to ACOG by Dr. Morley, ACOG withdrew this Educational Bulletin in the February 2002 issue of Obstetrics and Gynecology, the ACOG journal.”

http://www.whale.to/a/morley3.html
“ACOG Practice Bulletin 138 (B138) states: “Immediately after delivery of the neonate, a segment of umbilical cord should be doubly clamped, divided, and placed on the delivery table pending assignment of the 5-minute Apgar score.””

Katherine, it should be, but I’m not sure if it is as effective at increasing baby’s iron stores. Many of the studies I looked at included some c-sections, but I don’t recall seeing outcomes separated by delivery type. I’ll look into this and see if I can find more info.

Katherine, it seems like the research is really limited on DCC in c-sections. Just copying this over from a review:

Overall, there is very limited information on the optimal
timing for cord clamping at Caesarean section. The
available data are equivocal and based on relatively
small studies. It remains uncertain that placental
transfusion even occurs with DCC at the time of Caesarean
section.

If I am lucky enough to have a VBAC with a second child then I want to have delayed cord clamping. I hope that the second time around that I get to have a natural child birth and a baby born on time. I didn’t get the chance since my son made his debut at 33 weeks. We did however get free cord blood banking for 5 years from the downer situation.

Just wanted to add my opinion that delayed cord clamping and cord blood banking are not compatible. It’s vital for banking to get as many hematopoietic stem cells as possible as the viability is low, especially after freezing. A large number of these stem cells are needed if a transplant is ever necessary in the future. For reputable banks its simply not worth the risk to add in DCC.http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69323-9/fulltext
I enjoyed this article very much but thought I’d add that this is one of those highly controversial areas where studies have differed widely in the potential benefits of DCC for over a decade.
I think this speaks to the real issue; we simply don’t have enough research in obstetrics. All of these studies have small ns with pathetic stats. We deserve a better investment in OB research!

Thanks so much for adding your comment! After doing more reading on this topic, I appreciate the caution that DCC and cord blood banking probably aren’t compatible. I think that cord blood donation is great (just not available to everyone), and if that is something parents are interested in, I don’t think they should hesitate to clamp immediately for the sake of getting a usable cord blood sample. I did read a bit about expansion of hematopoietic stem cells, which would allow for greater transplant success with smaller samples. It sounds like we’re not there yet, but it is promising and definitely something to keep an eye on for the future.
Nice review of this: http://www.ncbi.nlm.nih.gov/pubmed/22958984

I know that DCC is still controversial, but I don’t really understand why. I can’t find evidence of risks of DCC, except for a few studies finding slightly increased risk of jaundice. On the other hand, there are some pretty good studies showing benefits (hence, risks of ECC) – definitely in preemies and in term babies as well. However, I do understand if clinicians are hesitant about changing the way they practice given that ECC has been the norm for so long and the litigious nature of obstetrics. Or, they just don’t know about the literature in this field.

The WHO and International Federation of Ob/Gyns no longer recommend early clamping but stop short of recommending DCC. After the 2008 Cochrane review on DCC was published, ACOG said, “the evidence doesn’t seem sufficiently strong for a change in policy, but it does encourage a relaxed approach to the timing of cord clamping” (quoted by Garogalo and Abenhaim 2012). The SOG of Canada does recommend DCC for preemies but says the jury is still out for term babies. I understand wanting more evidence before writing a policy one way or the other, but these organizations are also saying that there isn’t a compelling reason to cut the cord early.

All of this said, the benefits of DCC in term babies in developed countries aren’t overwhelming. These babies have the benefit of testing for anemia (though not always iron deficiency) later in infancy and getting supplements and fortified foods if needed. In a delivery where there is any risk of DCC – apparent or real – I’d cut the cord and get the baby the help she needs. But for a healthy baby and an uneventful delivery – why not?

I think you break it down perfectly here!
I meant that the research on DCC is controversial as some studies show a benefit while others do not. It seems to go endlessly back and forth with small studies finding conflicting results on anemia and higher stem cell levels. But I agree there’s no real evidence that its harmful.
I know doing research on pregnancy and childbirth is incredibly challenging but it annoys me that there’s so few OBs that do this important research. This is one of those areas where you’d love to see a definitive answer so that more women could benefit.
As far as DCC vs cord blood banking, I don’t think there’s any right choice, its a personal decision. Expanding hematopoietic stem cells would be a great way to have both in the future. :)

Hi Alice, I don’t think we met while we were in Davis (I graduated in 2006 and left in 2007), but I was happy to come across this post via the Facebook delayed clamping page. Thanks for such a great summary of the evidence and for spreading the word!

Hi Camila! So nice to hear from you. I started at Davis in 2004, so we overlapped by a few years but I’m not sure we ever met. I remember you giving a seminar about delayed cord clamping, and I can probably count on one hand (OK, maybe two) the seminars that I actually remember:) I’ve enjoyed reading your papers and following the DCC story since. Hope you are doing well! Congrats on your own little guy!

“If the cord is clamped immediately, you can make up for the lost iron” If iron was all that was lost, there would be no cord blood banks. The reason there are cord blood banks is that cord blood is much, much more valuable and more complex than just one chemical element. Most valuable are of course the stem cells. The baby needs the stem cells now, then there is less risk of ever needing banked cord blood in the future! There are also stem cells in breast milk, perhaps (more) researchers should look into breast milk for potential treatments rather than robbing babies of this vital life source that is only available at birth. Breast milk, on the other hand, is more readily available and many mothers produce a surplus.

I persuaded my OB to delay cord cutting for 30 seconds after my c-section, she was not in favor of doing it any longer than that because she wanted to “close me” up and she couldn’t hand me my son to hold due to the surgery set up etc, so she had to hold my baby for that time. This was 18 months ago and I felt it was worth the inconvenience and the awkward discussion wi my OB because of the asthma my first son has suffered from. I had read about women that swore by this delay cord cutting procedure that it could be beneficial to prevent asthma. Your post doesn’t discuss the benefits of that so I am assuming it is not a wide spread idea? But I was desperate to help my second son in any way I could. By the way, I have read about natural c-sections, this procedure is part of that delivery plan. Thanks for the wonderful post!

It surprised me that it wasn’t more pro-delayed clamping. It, and the Cochrane review, do note more need for phototherapy for jaundice with delayed clamping, which I see other reviews deny. I don’t know what to think there.

Thanks for sharing this – I hadn’t seen it yet. I’m not sure why the hesitancy to endorse delayed clamping. The increased incidence of phototherapy is definitely a valid concern, but the findings on this are mixed. I don’t understand why ACOG doesn’t recognize the benefits of DCC in “settings with rich resources.” Iron deficiency is not at all uncommon in the U.S., and many babies are born here outside of settings with rich resources.

My experience as a home birth midwife and a young midwife in PNG where there was only very basic newborn resuscitation equipment plus the studies about the impact of cord clamping on premature babies questionsif there is ever any situation where early cord clamping is OK! Also see http://www.youtube.com/watch?v=EQ11cI-qOaY

I don’t know if the statement that polycythemia is not dangerous is completely accurate. Increased hematocrit causes increased blood viscosity. Increased blood viscosity can cause changes in blood flow which can affect the delivery of certain substances (like glucose) that rely on the flow of plasma. Doesn’t hypoglycemia (which is already a possible issue a newborn can have) pose enough of a risk to question the total benefits of delayed cord clamping? Just curious, this is a new concept to me.

I meant that while the incidence of polycythemia has been shown to increase with DCC in some studies, those same babies had no symptoms and didn’t require treatment. So for those babies, polycythemia didn’t seem to pose a clinically-significant risk. I can see that my wording is sloppy in this paragraph, though. I’ll correct it to make it more clear. I wasn’t trying to say that polycythemia was never dangerous.

As far as hypoglycemia, I don’t recall seeing that mentioned as a concern with DCC in all my reading of the topic. I just did a quick PubMed search for DCC and hypoglycemia, and that didn’t turn up anything. I scanned some of the more recent reviews on DCC and didn’t find mention of it. If you find any research on it, let me know!

Hi Alice,
we used DCC with my son back in 2006. None of the obstetricians had ever heard about it, but they didn’t see it as a problem. When the baby came out, the first thing the Doctor did was to clamp the cord, and I had to gently remind him to unclamp the cord! (We just put a stop watch on for 5 mins).

Afterwards, all of the nurses commented how pink he was – which was apparently quite novel for them. If the baby had that extra 30% of blood inside at birth, there would be no way it would ever get out naturally!

(P,S, Sorry about my rant on fluoride on the other post. I know I can’t support my beliefs scientifically on this issue. So I’m happy to wait for more science to come along. I’ll just exercise my free will to keep fluoride out of my family for the time being. If I’m wrong, no harm done.)

This is one of my favorite pieces on this topic and gives a different way to think about babies in need of resuscitation, etc. Dr. Sloan has also written another piece on DCC more recently. http://www.scienceandsensibility.org/?p=5730

I had intended to do this with my first three years ago, but after I delivered him, the dr said the cord was short, and that my options were for my husband to hold the baby down there while we waited, or for her to cut the cord. In the heat of the moment, I had her cut the cord. I don’t know if I regret it or not, because he wound up jaundiced. But I wonder how common it is to have a short cord that causes a problem.

Good question, and I’m not sure of the answer. Someone who has attended a lot of deliveries might be able to tell us! Most of the studies have actually held the baby at the perineum to maximize placental transfer to the baby (so as not to work against gravity), but a recent study showed no difference in placental transfer whether baby is held at perineum or on mom’s chest. But you’re right that it’s awkward to hold a slippery baby so low, whether because of a short cord or some other reason!

WHO released a briefing (4 page) and full Guideline (24 pages) in 2014, which recommend delayed cord clamping unless resuscitation is required and cannot be performed with the cord still attached.
In the UK, national guidelines now promote delayed cord clamping (links copied below).

WHO released a briefing (4 page) and full Guideline (24 pages) in 2014, which recommend delayed cord clamping unless resuscitation is required and cannot be performed with the cord still attached.
In the UK, the national college and national health guidelines now promote delayed cord clamping (Links copied below)

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I'm Alice Callahan. I'm trained as a research scientist and have a PhD in Nutrition. I use my background in science to investigate parenting questions and find evidence-based answers. No mommy wars here - just science, and empathy and respect for one another.

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